Personal Training Intake Form

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First Name

Last Name

Phone

Email

Age

Gender

Male

Female

Emergency Contact

Emergency Contact Phone

Preferred Session Times

Day & Time

Day & Time

Day & Time

Day & Time

Day & Time

Day & Time

Day & Time

Day & Time

Day & Time

Preferred Trainer

Heather Frank

Tana Greene

Sara Pickering

Katy Fox

No preference

Participant's Health History

Name of Physician

Physician's Phone

Does your physician know you are taking part in this exercise program?

Yes

No

Describe your current exercise program:

What are your goals?

Are you taking any medications or drugs?*

No

Yes

If yes, what are you taking?

Do you now have, or have you had in the past: (Please explain "yes" answers in comment section at bottom of form.)

*History of heart problems, heart attack, chest pain, or stroke?

Yes

No

*Increased blood pressure?

Yes

No

*Diabetes or a thyroid condition?

Yes

No

*History of heart problems in immediate family?

Yes

No

Any chronic illness or condition?

Yes

No

Difficulty with exercise?

Yes

No

Advice from physician not to exercise?

Yes

No

Surgery within the last 12 months?

Yes

No

Pregnancy? Now or within the last 3 months?

Yes

No

History of breathing or lung problems?

Yes

No

Muscle, joint, or back disorder, or any previous injury still affecting you?

Yes

No

Cigarette smoking habit?

Yes

No

Obesity? More than 20% over ideal body weight?

Yes

No

Increased blood cholesterol?

Yes

No

Hernia or any condition that may be aggravated by lifting weights?

Yes

No

Have you had any pain or discomfort with exercising in the past?

Yes

No

If you answered yes to any of the health history questions, please explain here:

* If an asterisk question is marked yes, a physicians release form must be completed and signed before personal training sessions can begin. Please have your physican fax the form to Suzi Shankweiler at 303-833-7068. A certified trainer will call you to set up an appointment within 72 hours of submitting this form.